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Behaviour and mood (NPI-Q)

Relative or carer questionnaire

Behaviour and Mood Changes Questionnaire (NPI-Q)

Best completed by a family member or carer who knows the patient well. It asks about changes in behaviour and mood, and how distressing they are for you. It takes 5–6 minutes.

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

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- Step 1 of 3

This should be best completed by a family member or carer who knows the patient well.

1. About You and the Patient

Please answer based on changes that have occurred since the patient first began to experience memory problems.

Only answer Yes if the symptom has been present during the last month.

If you answer Yes, then ONLY you answer a and b:

how severe the symptom is for the patient
how distressing it is for you as caregiver/informant

It will take 5-6 min to complete.

Informant details

Informant full name *

Phone *

Email *

Relationship with the patient *

Patient details

Patient full name *

Patient date of birth *

DOMAIN 1 — Delusions

1. Delusions: Does the patient have false beliefs, such as thinking that others are stealing from him/her or planning to harm him/her in some way? *

If Yes, answer questions below (a and b) or skip to the next domain question

1a. Delusions severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

1b. Delusions causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

How this symptom affects you: 0 not distressing; 1 minimal (slightly distressing, not a problem to cope with); 2 mild (generally easy to cope with); 3 moderate (not always easy to cope with); 4 severe (difficult to cope with); 5 extreme (unable to cope).

Email caregiver

DOMAIN 2 — Hallucinations

2. Does the patient have hallucinations such as false visions or voices? Does he or she seem to hear or see things that are not present? *

If Yes, answer questions below (a and b) or skip to the next domain question

2a. Hallucination severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

2b. Hallucination causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 3 — Agitation/Aggression

3. Is the patient resistive to help from others at times, or hard to handle? *

If Yes, answer questions below (a and b) or skip to the next domain question

3a. Agitation severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

3b. Agitation causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 4 — Depression/Dysphoria

4. Does the patient seem sad or say that he/she is depressed? *

If Yes, answer questions below (a and b) or skip to the next domain question

4a. Depression severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

4b. Depression causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 5 — Anxiety

5. Does the patient become upset when separated from you? Does he/she have any other signs of nervousness such as shortness of breath, sighing, being unable to relax, or feeling excessively tense? *

If Yes, answer questions below (a and b) or skip to the next domain question

5a. Anxiety severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

5b. Anxiety causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 6 — Elation/Euphoria

6. Does the patient appear to feel too good or act excessively happy? *

If Yes, answer questions below (a and b) or skip to the next domain question

6a. Euphoria severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

6b. Euphoria causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 7 —Apathy/Indifference

7. Does the patient seem less interested in his/her usual activities or in the activities and plans of others? *

If Yes, answer questions below (a and b) or skip to the next domain question

7a. Apathy severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

7b. Apathy causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 8 —Disinhibition

8. Does the patient seem to act impulsively, for example, talking to strangers as if he/she knows them, or saying things that may hurt people's feelings? *

If Yes, answer questions below (a and b) or skip to the next domain question

8a. Disinhibition severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

8b. Disinhibition causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 9 — Irritability/Lability

9. Is the patient impatient and cranky? Does he/she have difficulty coping with delays or waiting for planned activities? *

If Yes, answer questions below (a and b) or skip to the next domain question

9a. Irritability severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

9b. Irritability causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 10 — Motor Disturbance

10. Does the patient engage in repetitive activities such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly? *

If Yes, answer questions below (a and b) or skip to the next domain question

10a. Motor disturbance severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

10b. Motor disturbance causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 11 — Nighttime Behaviors

11. Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day? *

If Yes, answer questions below (a and b) or skip to the next domain question

11a. Nighttime behaviour disturbance severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

11b. Nighttime behaviour causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

DOMAIN 12 — Appetite/Eating

12. Has the patient lost or gained weight, or had a change in the type of food he/she likes? *

If Yes, answer questions below (a and b)

12a. Appetite disturbance severity *

Mild (noticeable, but not a significant change)
Moderate (significant, but not a dramatic change)
Severe (very marked or prominent, a dramatic change)

12b. Appetite disturbance causing caregiver distress *

Not distressing at all
Minimal
Mild
Moderate
Severe
Extreme / Very severe

Consent and confirmation *

I confirm that I am completing this questionnaire as someone who knows the patient well. I believe the information provided is accurate to the best of my knowledge.
I understand this information will be used for clinical assessment and I have the patient’s permission to share it where appropriate.

Your answers are stored securely on this website for Dr Jha. They are copied into your clinical record and deleted from the website within 90 days. Privacy notice

Back to the pre-consultation questionnaires

Back to the 6-monthly review questionnaires

Behaviour and Mood Changes Questionnaire (NPI-Q)

This should be best completed by a family member or carer who knows the patient well.

1. About You and the Patient

Informant details

Patient details

DOMAIN 1 — Delusions

DOMAIN 2 — Hallucinations

DOMAIN 3 — Agitation/Aggression

DOMAIN 4 — Depression/Dysphoria

DOMAIN 5 — Anxiety

DOMAIN 6 — Elation/Euphoria

DOMAIN 7 —Apathy/Indifference

DOMAIN 8 —Disinhibition

DOMAIN 9 — Irritability/Lability

DOMAIN 10 — Motor Disturbance

DOMAIN 11 — Nighttime Behaviors

DOMAIN 12 — Appetite/Eating

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